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Journal of Back and Musculoskeletal Rehabilitation 29 (2016) 41–47 DOI 10.3233/BMR-150594 IOS Press

Kinesiophobia in relation to physical activity in chronic neck pain ˙Ilk¸san Demirbüken∗, Bahar Özgül, Tu˘gba Kuru Çolak, Onur Aydo˘gdu, Zübeyir Sarı and Saadet Ufuk Yurdalan Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Marmara University, Istanbul, Turkey

Abstract. BACKGROUND: Little research is available concerning physical activity and its determinants in people with chronic neck pain. OBJECTIVE: To explore the relation between kinesiophobia and physical activity and gender effect on these relations in people with chronic neck pain. METHODS: Ninety-nine subjects (34 men and 65 women) with chronic neck pain were participated in the study. Pain intensity was assessed with Visual Analog Scale and kinesiophobia degree was determined by using Tampa Scale of Kinesiophobia. Level of physical activity was assessed with short form of the International Physical Activity Questionnaire. RESULTS: There was no statistically correlation between neck pain intensity and kinesiophobia degree (p = 0.246, r = 0.123) and physical activity level (p = 0.432, r = −0.083). It was also found that kinesiophobia degree was not correlated to physical activity level (p = 0.148, r = −0.153). There was a negative correlation between kinesiophobia degree and physical activity level only for women, not for men (p = 0.011, r = −0.318). CONCLUSIONS: Our results showed that although people with chronic neck pain reported higher pain intensity and fear of movement, pain intensity and kinesiophobia degree did not associate to their physical activity levels. It can be speculated that high kinesiophobia degrees cause low physical activity levels for women, but not for men. Keywords: Kinesiophobia, physical activity, chronic neck pain, gender

1. Introduction Neck pain is a fairly common musculoskeletal condition within chronic pain problems and it effectuates up to 71% of adult population during their life time [1–5]. Sense of neck pain is not life threatening, but the individuals who suffer from severe neck pain are generally insufficient to go to work regularly [6]. Sick-leave due to neck pain, which women reported more often than men, can place a considerable annual financial burden on society [7–9]. Besides its healthcare costs and productivity loss, neck pain causes a ∗ Corresponding author: ˙Ilk¸san Demirbüken, Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Marmara University, Istanbul, Turkey. Tel.: +90 216 459 45 60; Fax: +90 216 399 62 42; E-mail: [email protected].

significant limited participation in physical activity of people with chronic neck pain. Physical activity is not only a requirement for preventing variety of chronic diseases, it is also a common management strategy for chronic musculoskeletal pain [10]. It has been well documented that people with chronic neck pain achieved pain relief by participating in exercise programs and sport activities [11,12]. But yet, Hallman et al. investigated physical activity of people with chronic neck-shoulder pain and indicated that pain group had increased lying time compared to controls [13]. Another study found that 70% of people with neck pain limited their physical activity moderately to severely [14]. On the other hand, Cheung et al. indicated mild disability due to neck pain did not affect the amount of physical activity of people with chronic neck pain compared to healthy people [15].

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Little research is available concerning physical activity level and its determinants in people with chronic neck pain with conflicting results. Moreover, no studies have investigated gender effect on physical activity level of people with chronic neck pain although women reported more sick leave compared to men [7]. It would be helpful to identify factors may have impact on physical activity levels in chronic neck pain to better understand illness management strategies. One of the reasons of physical activity limitations for the patients with musculoskeletal pain is ‘kinesiophobia’ [16]. ‘Kinesiophobia’, in other words ‘avoidance behavior due to fear’ was defined as ‘an excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or re-injury’ [17]. Pain-related fear that causes behavioral impacts may be a result or conversely a reason of increased avoidance of activity in musculoskeletal pain [18]. It is assumed to be pain-related experiences, combined with kinesiophobia, may be more disabling than pain itself [19]. Tampa Scale of Kinesiophobia (TSK) which was developed to measure the fear of movement in patients with low back pain has been also used to investigate kinesiophobia degree in the people with neck pain [20,21]. High fear of movement and/or (re)injury as measured with the TSK had been found to be associated with poor physical performance in people with spinal pain [22–25]. Conversely, a study of Pearson et al. demonstrated no significant association between neck strength and TSK scores in the subjects with chronic whiplash syndrome [25]. In 2006, Nederland et al. indicated that lower level of muscle activity was associated with the increase in the fear of movement during the transition of acute to chronic post traumatic neck pain [26]. However, there is a lack of study about the effect of kinesiophobia, which causes functional limitations, over the physical activity level of the people with neck pain, especially for chronic neck pain in the literature. Because of physical activity constitutes one of the treatment approaches for the patients with neck pain [10], investigating the factors that limit physical activity in these patient group would be beneficial to improve treatment strategies in the chronic neck pain. The aim of the present study was to explore the relation between kinesiophobia and physical activity in people suffering from chronic neck pain. Secondly we aimed to investigate whether gender affects or not the kinesiophobia degree and physical activity level in chronic neck pain.

2. Methods 2.1. Participants One hundred and thirty-nine subjects with chronic neck pain were participated in the study. Forty subjects who did not complete the questionnaires were excluded. A total of 99 subjects (34 men and 65 women) between the ages of 17 and 65 years, with a diagnosis of chronic neck pain were recruited from a Private Physiotherapy Clinic between September 2013 and July 2014. The subjects who had diagnosis of chronic neck pain (ongoing pain for at least 6 months), and were able to complete Turkish language written questionnaires included in the study. Subjects were excluded if they were over the age of 65, were unable to attend in any physical activity due to the limitations of cardiopulmonary, orthopedic and neurological systems, intake of analgesic medication within 24 hours, intake of psychiatric medication, had any musculoskeletal problems that may affect motor functions, had severe vision and hearing problems, and had any orthopedic surgery within the last 6 months. This study was approved by Marmara University Health Sciences Institute Non-Invasive Clinical Research Ethics Board. All participants gave their informed consent prior to assessments and they were given an explanation about the study procedure before participation. 2.2. Study design Demographic characteristics of subjects who accepted to participate in the study were recorded and pain assessment was performed by using Visual Analog Scale (VAS) [27]. Subjects were instructed to indicate the intensity of the pain by marking a 100-mm line anchored with terms describing the extremes of pain intensity [28]. Fear of movement/(re)injury was determined by using TSK. TSK consists of 17 questions rated on a 4-point Likert scoring (1 = strongly disagree, 4 = strongly agree). A total score is calculated between 17– 68 after reversal of items of 4, 8, 12 and 16. The high score according to the scale shows a high degree of kinesiophobia [23]. The validity and reliability of the Turkish version of questionnaire was carried out previously by Yılmaz et al. [29]. TSK score was divided into two degrees indicating ‘high kinesiophobia’ and ‘low kinesiophobia’. TSK score greater than 37 repre-

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sents ‘high kinesiophobia’ while score lower than 37 represents ‘low kinesiophobia’ degrees. Level of physical activity was assessed by using short form of The International Physical Activity Questionnaire (IPAQ) [30]. The questionnaire determines level of physical activity of individuals in the daily life. The subjects were asked questions about time spent on physical activity in the last 7 days. Vigorous physical activity (football, basketball, aerobic, rapid cycling, weight lifting, load carrying, etc.) duration (minute), moderate physical activity (lightweight load bearing, cycling at normal speed, folk dancing, dance, bowling, table tennis, etc.) duration (minute), daily walking and sitting durations (minute) were questioned through the survey. Duration of physical activity obtained from the survey was calculated as total physical activity score (MET-minutes/week) by turning MET corresponding to the basal metabolic rate by the following formulas. Vigorous physical activity (MET-minute/week) = 8.0 × duration of vigorous physical activity × day of vigorous physical activity Moderate physical activity (MET-minute/week) = 4.0 × duration of moderate physical activity × day of moderate physical activity Walking score (MET-minute/week) = 3.3 × duration of walking × number of days of walking Total physical activity score (MET-minute/week) = Walking + Moderate physical activity + Vigorous physical activity scores [30]. Data was analyzed by using SPSS version 11.5 (SPSS Inc. Chicago) for Windows Statistical Program. Statistical significance was set at p < 0.05. The relationship between chronic neck pain intensity & TSK and IPAQ scores of subjects and also separately for subgroups of men and women were investigated by using Pearson correlation test. Comparing the differences between neck pain intensity, TSK and IPAQ scores of men and women was analyzed by using Mann Whitney U test.

3. Results A total of 99 subjects (35 men and 64 women) were recruited in the study. The age of subjects ranged between 18 and 65 years with a mean of 43.65 ± 12.83 years. Demographic characteristics, pain intensity, kinesiophobia and physical activity scores of subjects are shown in Table 1. Distributions of subjects according to gender, kinesiophobia and physical activity scores are shown in Ta-

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Table 1 Demographic characteristics, pain intensity, kinesiophobia and physical activity scores of subjects Variable Age (years) Height (cm) Weight (kg) Body mass index (kg/m2 ) Pain intensity (cm) Kinesiophobia (TSK) Physical activity (IPAQ)

Mean ± SD 43.65 ± 12.83 165.55 ± 8.77 74.26 ± 13.68 27.38 ± 5.24 6.47 ± 1.96 41.82 ± 5.22 3749.20 ±2924.16

SD is standard deviation, TSK represents Tampa Scale of Kinesiophobia, IPAQ represents International Physical Activity Questionnaire. Table 2 Distribution of subjects according to gender, kinesiophobia and physical activity scores Variable Gender Men Women TSK High kinesiophobia Low kinesiophobia IPAQ Low activity Moderate activity Vigorous activity

n (%) 35 (34.4) 64 (65.6) 73 (80.2) 18 (19.8) 7 (7.7) 45 (49.5) 39 (42.9)

n is number, TSK represents Tampa Scale of Kinesiophobia, IPAQ represents International Physical Activity Questionnaire.

ble 2. Of the subjects, 65.6% were women and 34.4% were men. Seventy-three (80.2%) of subjects had high kinesiophobia scores and 18 (19.8%) had low kinesiophobia scores according TSK. The majority of subjects (49.5%) had moderate physical activity level, 42.9% had vigorous physical activity level and 7.77% had low physical activity level (Table 2). There was no statistically correlation between neck pain intensity and kinesiophobia degree (p = 0.246, r = 0.123) and physical activity level (p = 0.432, r = −0.083). In addition, it was found that kinesiophobia degree was not correlated to physical activity level (p = 0.148, r = −0.153). Neck pain intensity and kinesiophobia degree of women were significantly lower than men (p = 0.002, p = 0,040) while there was no gender difference in physical activity levels (p = 0.077) (Table 3). When the relationship between neck pain intensity and kinesiophobia degree and physical activity level was analyzed separately for subgroups of men and women, no correlation between neck pain intensity and kinesiophobia degree and physical activity level were found. While kinesiophobia degree was not correlated to physical activity level for men (p = 0.811,

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Table 3 Pain intensity, kinesiophobia and physical activity scores for men and women

Pain Intensity (VAS) Kinesiophobia (TSK) Physical activity (IPAQ)

Men (Mean ± SD) (n = 35) 5.59 ± 2.07 40.39 ± 6.35 4495.48 ± 3332.79

Women (Mean ± SD) (n = 64) 6.88 ± 1.73 42.39 ± 4.50 3112.05 ± 2411.25

t

p

3.229 −2.333 1.789

0.002∗ 0.040∗ 0.077

∗p

< 0.05, Independent Samples T test, SD is standard deviation, TSK represents Tampa Scale of Kinesiophobia, IPAQ represents International Physical Activity Questionnaire.

Fig. 1. Relationship between kinesiophobia and physical activity scores for women.

r = −0.043), there was a negative correlation of weak strength between kinesiophobia degree and physical activity level for women (p = 0.011, r = −0.318) (Table 4, Fig. 1).

4. Discussion There is an increasing tendency to investigate chronic neck pain and its determinants due to increasing prevalence of neck pain in the population [15,31]. Despite the fact that kinesiophobia is considered as a predictive factor of chronic disability and development of pain in musculoskeletal disorders, less research has been conducted regarding pain and kinesiophobia in people with chronic neck pain [32–34]. The noteworthy finding in the current study was that although patients with chronic neck pain reported higher pain intensity and fear of movement, these factors did not significantly associate to their physical activity levels. The mean TSK score (41.8; reflecting high kinesiophobia degree) in the current study was comparable to scores of previous studies includ-

ing people with neck pain. The study of Cheung et al. reported mean TSK scores of their subjects with chronic neck pain as 37.6 which was too close to cut off score for high and low kinesiophobia degrees recalling scores over 37 represents high kinesiophobia while scores below 37 represents low kinesiophobia degree [15]. The mean TSK score was 26.1 in the study of Feleus et al. investigating kinesiophobia in patients with non-traumatic arm, neck and shoulder complaints but they used TSK with 13 items which is scored from 13 to 52 points. Still little is known about the degree of kinesiophobia and its associated variables since the first research using the TSK scale to measure kinesiophobia degree in patients with neck pain was conducted in 2004 [35]. Furthermore, most of the studies investigated neck pain and kinesiophobia have a positive bias towards to including whiplash disorder sufferers in their experimental design although it is not the only ostensible form of neck pain [35]. The mean neck pain intensity measured in the current study was 6.47 according to VAS which is considered to be over moderate pain intensity [36]. However, the findings of the current study showed that there was no association between neck pain intensity and kinesiophobia degree of patients in our study. The study of Cleland et al. found a weaker relationship between measures of kinesiophobia degree and pain intensity among patients with mechanical neck pain than has been reported among patients with low back pain. They suggest that TSK may not adequately assess kinesiophobia in patients with neck pain because it was originally developed for patients with low back pain [32]. Conversely, TSK score has been previously shown to have a relationship to neck pain intensity by study of Buitenhuis et al. It is important to note that they investigated kinesiophobia on the neck symptoms after a motor vehicle accident [37]. It may be that the patients with chronic neck pain may not experience the same magnitude of fear and avoidance behavior against pain as do patients with traumatic onset of neck pain. This result of the current study suggests that pain intensity may not be directly affecting the degree of kinesiophobia in patient population with chronic neck pain.

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Table 4 Relationship between pain intensity, kinesiophobia and physical activity scores for men and women Men (n = 35) Women (n = 64)

Pain intensity (VAS) Kinesiophobia (TSK) Physical activity (IPAQ) Pain intensity (VAS) Kinesiophobia (TSK) Physical activity (IPAQ)

Mean 5.59 40.39 4495.48 6.88 42.39 3112.05

SD 2.07 6.35 3332.79 1.73 4.50 2411.25

TSK 0.880 − − 0.510 − −

IPAQ 0.652 0.811 − 0.931 0.011∗ −

∗p

< 0.05, Pearson correlation test, SD is standard deviation, TSK represents Tampa Scale of Kinesiophobia, IPAQ represents International Physical Activity Questionnaire.

Furthermore, our results showed that pain intensity did not affect physical activity level of people with chronic neck pain, either. The current finding is consistent with evidence from Cheung et al. that demonstrated no differences between physical activity levels of people with chronic neck pain and healthy controls [15]. From another perspective, Hallmann et al. have indicated that the daily physical activity level was not significantly different between people with chronic neck-shoulder pain and healthy controls but patient group seemed to have a different physical activity pattern than healthy controls with being less active during leisure time and more active in the morning [13]. Reduced levels of physical activity are mostly reported in individuals affected with chronic low back pain among pain complaints in spinal region [38–40]. It might be speculated that pain at the neck may not affect full body movements as pain at low back does. Interestingly, 80.2% of the subjects in the current study reported high kinesiophobia degree and their kinesiophobia degree had no association with their physical activity level. The latest evidence found that people with chronic neck pain and healthy controls in their study did not differ in physical activity levels although neck pain group reported higher fear of movement. They have used both subjective and objective tools to assess physical activity level and concluded that both self-reported and objectively measured physical activity levels were comparable in people with neck pain [15]. We used IPAQ which is self-reported physical activity questionnaire to assess physical activity levels of people with chronic neck pain. It may be that the IPAQ mostly reflects the lower extremity activities and may not accurately measure physical activity levels in patients with neck pain. Since there is a limited number of evidence on neck pain and physical activity, it can be suggested that there is a need for development of more applicable and reliable tools to assess physical activity level of people with neck pain. A female predominance on the prevalence of neck pain in the general population was reported by many

researchers [41–44]. A study of Wignhoven et al. stated a significant association between female sex and chronic neck pain [45]. Consistent with the literature, the majority of subjects in the current study who suffer neck pain were consisted of women (65.6% of total participants) with significantly higher neck pain intensity than men had. Beside the difference of neck pain intensity between men and women, current finding showed that kinesiophobia degree of women with neck pain was significantly higher compared with men. Branstrom et al. showed that pain intensity correlated with kinesiophobia degree in both of men and women with general musculoskeletal pain [46]. However, there was no relation between neck pain intensity and kinesiophobia degree in our study for both men and women. Nevertheless there is no study investigating gender effect on the relation between neck pain and kinesiophobia degree that we can compare with our results. Moreover, there was no significantly difference between physical activity level of men and women in the current study although men had higher physical activity level than women. Physical activity level decreases when kinesiophobia degree increases for only women, while pain intensity had no effect on physical activity levels in both genders. The relation between physical activity level and kinseiophobia degree for women with chronic neck pain in our study supports the information that avoidance behavior causes less physical activity [22]. This relation suggests coping with fear of movement may be a target for increasing physical activity level for women with chronic neck pain. Men may have developed alternative cognitive process to manage their fear-avoidance beliefs that affect their kinesiophobia [32]. This study is the first in the literature that investigated the effect of kinesiophobia on physical activity level separately according to gender, therefore further researches are warranted. We suggest investigating the effect of kinesiophobia on physical activity level with including only men and only women to avoid gender bias in the further studies. It should

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be also noted that patients with chronic neck pain included in the current study were patients had already started a physiotherapy treatment in a private physiotherapy clinic and there was no standardization of their treatment program and assessment sessions by the date of initiation of treatment. This may present a bias towards increasing physical activity level of patients with chronic neck pain in the last few days before investigation.

5. Conclusion In a conclusion, the results of this study indicated that although people with chronic neck pain reported higher pain intensity and fear of movement, pain intensity and kinesiophobia degree did not significantly associate to their physical activity levels. When gender effect was considered on measured parameters in patients with chronic neck pain, it was seen that high kinesiophobia degrees cause low physical activity levels for women, but not for men. The findings of this study also highlight the need for further studies on relation between pain intensity, kinesiophobia degree and physical activity level in people with chronic neck pain. Better understanding of the relation between all these parameters in neck pain will help to develop more effective treatment programs for patients with chronic neck pain, further, particular strategies for men and women.

Acknowledgement The authors would like to thank to physiotherapist Harun Kiloatar for his assistance in clinical assessment process.

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Kinesiophobia in relation to physical activity in chronic neck pain.

Little research is available concerning physical activity and its determinants in people with chronic neck pain...
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